Around 60% of aged care residents require more than four hours of care per day. Shutterstock

Topping the list ofprioritiesis to uncover substandard care, mistreatment and abuse, and to identify the system failures and actions that should be taken in response.

But we don’t need a royal commission to tell us the number-one thing that can improve care in nursing homes: implementing minimum staffing levels.

Based on our research from 2016, the Australian Nursing and Midwifery Federation recommends residents receive 4 hours and 18 minutes of care per day for optimal health and well-being.

It’s also important to get the right mix of staff performing for these hours and minutes. Half of the care should be provided by care workers (who undertake a short TAFE course), 30% by registered nurses (who complete a three-year bachelor degree at university), and 20% by enrolled nurses (who complete an 18-month diploma).

Nurse ratios in hospitals

It’s no surprise nurse shortages affect patient care. Nurse staffing shortfalls in hospitals have beenassociated withpoorer patientoutcomes, longer stays in hospital, and a higher risk of death within 30 days of discharge.

Poor staffing causes stress and frustration among nurses, who constantly feel rushed and unable to provide the type of care their patients deserve. This leads to greaterjob dissatisfaction and burnout.

One way to ensure nurse staffing levels is to implement mandatory nurse-to-patient ratios. Californiadid this in 1999, when it mandated ratios ranging from one nurse to two patients in intensive care, to one nurse to six patients for women who had given birth.

After the ratios were implemented, the nurses’ patient loads decreased and they reportedbeing able to providebetter quality care. They also felt more job satisfaction and were less likely to burn out. Importantly, rates of complications and premature death decreased.

Minimum aged-care staffing

Seemingly small tasks in aged care can have a big impact on residents. If they don’t receive adequate assistance at meal times, for instance, they may lose weight and become malnourished. If they’re bed-bound and aren’t moved frequently enough, they’re at risk of developing painful pressure sores.

As with hospital-based care, minimum staffing ensures staff have enough time to complete these important tasks andhas been associatedwith improvements in health outcomes for residents with multiple illnesses.

Missed or delayed care can have an enormous impact on residents.Elien Dumon/

What happens in Australia?

AllAustralian states and territorieshave legislation to determine the minimum staffing levels in hospitals to ensure patients receive timely care and close monitoring. But no such legislation exists in the aged-care sector.

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In phase one, we tested six “profiles” for residents requiring between 2.5 and 5 hours of nursing care daily, using the de-identified data of 200 residents. We then recruited experienced registered nurses to time and record what amounted tonearly 2,000 nursing and personal care interactionsin hospitals, aged care and rehabilitation facilities.

We ran the six “profiles” made up of timed care activities through seven focus groups of nurses working in aged care to determine the proportion of residents who meet each profile.

Nurses and carers want the time to provide quality care to residents. Alexander Raths/Shutterstock

Overall, we found more than 60% of aged care residents required four or more hours of care per day. This rate is likely to be similar in most aged-care facilities across the country.

Thesecond componentof our research involved surveying 3,206 staff working in aged care to determine the amount and types of care missed and the reasons why. This is care missed or delayed because of multiple demands, inadequate staffing and material resources, or communication breakdowns.

Staff believed care was being missed in all facilities, with higher levels of missed care reported in privately owned facilities (both for-profit and not-for-profit).

Author provided

Unscheduled tasks such as responding to call bells and to toileting needs within five minutes were most likely to be missed – as were the social and behavioural needs of residents.

Complex care activities such as wound care, medication and end-of-life care were less likely to be missed, although there were deficits in some areas.

When asked to indicate the reasons why care was missed, the respondents cited:

having too few staff

the complexity of resident needs (for example, more residents receiving palliative care and with dementia)

Beware cost saving

Many of the problems in the aged-care sector can be addressed with adequate staffing, and ensuring residents receive, at a minimum, the required 4 hours and 18 minutes of care each day. But staffing hours should not be increased by replacing nursing staff (who have clinical education and skills) with lower-skilled care workers.

In recent years, some residential aged-care providers have been reducing the number of enrolled nurses employed and substituting them with care workers to offset staffing costs. Between 2003 and 2012,21,000 more care workers were employed, along with 2,326 fewer registered nurses.

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It’s important to ensure the skill mix includes enough registered nurses for the complex assessment and specialised nursing care now required by residents.

It’s clear the royal commission must investigate staffing shortfalls rather than simply blame nurses and carers who often struggle to provide the level of care they’d like to.